Unless you live deep underground – very deep – you surely know Vermont's health care exchange, known as Vermont Health Connect, is launching this week. The state's $9.5 million promotional campaign (paid for by the federal government) has left few stones unturned in its effort to reach out to the roughly 100,000 people who will be required to purchase health insurance through the exchange in January. I attended six different forums, listened to dozens of questions and spent a few choice hours on the exchange website – all in a quest to understand the future of Vermont health coverage. Here are a few general impressions.

The happiest people with Vermont Health Connect are likely to be moderate income Vermonters with household incomes too high to qualify for subsidized care (Dr. Dynasaur, Catamount, VHAP) but not high enough to purchase adequate coverage. A combination of federal and state subsidies through the exchange will make high-quality health care much more affordable. The simplicity of the exchange is also a plus. Eighteen choices, laid out side by side in an identical format – as long as your eyes are good, comparison shopping is easy. Add in the comfort of knowing each plan in the exchange must meet minimum benefit requirements and have adequate reserves to pay claims. If you do your homework, or seek assistance from state-trained navigators or your local insurance broker, surprises will be kept to a minimum. Vermont Health Connect goes a long way towards simplifying and commoditizing a complex product.

The unhappiest people with Vermont Health Connect are likely to be those who want choice. With such a heavy emphasis on price, the two carriers have had to sharpen their pencils and wring out costs. This they've done by narrowing their plan benefits. To cite just one example, my son is in college in Colorado. His care is currently provided by a Colorado physician in the MVP network. Unfortunately, none of the MVP plans offered through the exchange will have out-of-state coverage, except in the case of an emergency. It brings to mind Henry Ford's dictum on cars: "People can have the Model T in any color – so long as it's black." My son can have any color health plan he wants, so long as it's Blue (Cross). People with unique needs are unlikely to be pleased with the exchange. The same holds for people with particularly generous plans or people who only want catastrophic coverage. The system only works if uniformity is enforced.

Vermont Health Connect does offer 18 plans, but a closer inspection reveals very little real choice. Blue Cross Blue Shield and MVP each offer nine substantially similar plans. You can purchase a BCBS plan, or you can pay more and purchase the same plan from MVP. I'm left wondering whether anyone will purchase an MVP plan. The plans have minor differences (as my son's example illustrates) and MVP tells me they expect to keep existing happy customers who will stay with the company despite the price disadvantage. Good luck with that. At the end of the day, we may have de facto if not de jure single (private) payer in the small group and individual market.

None of this would matter if Vermont had followed the lead of the other 49 states and made the exchange optional. The fact that every small group and individual health care consumer in Vermont will be required to seek coverage through the exchange in the next three months magnifies the importance of every defect, every change and every deadline. If the exchange were optional, perhaps for the first two or three years, the state would have had time to work through the problems, fine tune the offerings and – ultimately – succeed by acclaim rather than by mandate. The lack of choice created an uneasy feeling at the forums I attended.

To its credit, the Department of Vermont Health Access, the state agency overseeing the exchange, has thrown substantial resources into public education. Many people at the public forums had already been in contact with Vermont Health Connect. Almost without exception, they reported prompt attention to their phone calls and emails. I can report the same. Happy or unhappy, Vermont Health Connect is going to happen and the state is doing what it can to smooth out the speed bumps.

Greshin is the state representative for Washington 7 and lives in Warren.